Julie Rovner has spent over forty years patrolling the hallways of power in Washington, documenting the intricate and often frustrating evolution of American healthcare. As the chief Washington correspondent for KFF Health News and the host of the “What the Health?” podcast, she has become one of the nation’s most trusted voices in health policy. Her perspective is shaped by a deep historical memory, spanning from the collapse of the Clinton health plan to the hard-fought passage of the Affordable Care Act. Rovner famously compares our current healthcare system to a “giant Jenga tower”—a structure that is increasingly wobbly as critical pieces are yanked out by administrative cuts and shifting political priorities. In this conversation, we explore the quiet erosion of public health safety nets, the human consequences of insurance policy changes, and the looming political showdown she expects to define the next decade of American medicine.
The interview explores how recent federal budget cuts and administrative shifts are impacting the daily lives of Americans, specifically focusing on the tracking of foodborne illnesses and the rising costs of private insurance. We examine the “slow-motion repeal” of the Affordable Care Act, the introduction of work requirements in Medicaid, and the heartbreaking loss of funding for family caregivers who perform essential medical tasks at home. Rovner offers a sobering look at the drain of scientific expertise from government agencies and discusses the widening ideological gap between political parties. Ultimately, she provides a detailed forecast for the 2028 election cycle and explains why she believes the entire nation—including those with insurance—is reaching a breaking point that will necessitate a massive public debate.
You’ve frequently used the metaphor of a Jenga tower to describe the American healthcare system. In light of the recent Cyclospora outbreak and the scaling back of federal tracking for foodborne pathogens, how is that tower holding up today?
It really does feel like we are reaching a tipping point where those missing pieces are causing the whole structure to sway dangerously. We are currently about a month into a very significant outbreak of Cyclospora, a parasite that causes truly miserable symptoms like explosive diarrhea, yet because federal tracking for half a dozen foodborne pathogens was cut last year, we still don’t know what’s causing it. I’ve seen medical professionals recommending that people simply stop eating fresh fruits and vegetables like raspberries or salad bar items for a week or two because this specific parasite isn’t always something you can just wash away. In a normal world, our public health infrastructure would have identified the source by now, but we are currently operating in a state of confusion that feels like a flashback to the early days of COVID-19. It is a perfect, albeit gross, example of what happens when you pull out the professional surveillance sticks that keep the public safe; suddenly, no one knows if their dinner is going to make them sick.
Beyond the visible public health crises, you’ve noted a quieter, more systemic drain of expertise from health agencies. What does it mean for the country when career scientists are replaced by political decision-makers?
The loss of institutional knowledge over the past year has been staggering, with a massive amount of expertise simply walking out the door due to buyouts and layoffs. When you have large cuts at agencies like the FDA or the CDC, you aren’t just losing names on a payroll; you are losing people with decades of experience in navigating complex medical and scientific challenges. We are seeing a shift where political appointees are now making decisions that were historically the domain of career professional scientists and doctors. This leads to a situation where things aren’t happening behind the scenes—grants that Congress ordered to be distributed are stalled, and the “cut first, answer questions later” mentality becomes the standard operating procedure. For the people involved at the lower levels of these agencies, it is incredibly demoralizing to watch that expertise vanish, and for the public, it means the people tasked with our safety might not actually know as much as their predecessors did.
There is a lot of talk about a “slow-motion repeal” of the Affordable Care Act. How are these administrative changes manifesting for the average family trying to buy insurance?
There is no question that the Affordable Care Act is being dismantled, even if the formal name remains. Most of the taxes that supported the financing of the law—taxes on health insurers, drug companies, and large businesses—have been stripped away by lobbyists, leaving the funding to come directly from the federal treasury. We are seeing millions of people drop their insurance because subsidies have expired or decreased, forcing them into “crummy” plans that offer very little real protection. Some of these newer rules encourage plans where families might have to spend $30,000 or more out of pocket before their insurance even begins to kick in. At its peak, the ACA helped bring the uninsurance rate down to about 8%, the lowest on record, but now we are seeing a reversal where people might technically have insurance but still cannot afford to get the medical care they actually need.
Medicaid is often a lifeline for the most vulnerable, yet we are seeing new restrictions and funding cuts. How are these changes affecting family caregivers and those who are medically frail?
We are seeing a very harsh reality play out where the “optional” programs in Medicaid are the first to be slashed when states face funding shortfalls. In my home state of Maryland and several others, notices are going out to families telling them that their checks for taking care of elderly or disabled relatives are simply going to stop. There is a narrative being pushed by some officials that this money is just paying kids to carry groceries or bring in the newspaper, but that couldn’t be further from the truth. These caregivers are performing incredibly difficult and essential tasks, like changing feeding tubes and assisting non-ambulatory patients in and out of bed or onto the toilet. If you make it impossible for families to provide this care at home, many of these patients will end up in institutions, which is not only worse for their quality of life but will end up costing taxpayers significantly more in the long run.
With the political landscape becoming increasingly polarized, you’ve mentioned that the “middle ground” in healthcare policy seems to be disappearing. Where does that leave the prospects for future reform?
In the forty years I’ve been covering this, the only time we’ve seen big achievements in healthcare is when the two sides come together in a compromise. Even the Affordable Care Act, which passed with only Democratic votes, was originally based on a Republican idea implemented by Mitt Romney in Massachusetts. But today, the middle ground is a ghost town; the left is moving toward Medicare for All while the right wants to get the government out of healthcare entirely and let the free market take over. Even someone like Joe Biden, who was one of the few in 2020 to stick to just expanding the ACA rather than endorsing a total overhaul, is finding that middle ground harder to maintain. We aren’t even seeing much cooperation on “little stuff” anymore because the ideological divide has become so deep that neither side wants to give the other a win.
You’ve spent your career submerged in these heavy, often depressing topics, and you’ve even joked about your wardrobe reflecting the “unprecedented times” we live in. How do you personally handle the exhaustion of tracking this “Jenga tower” as it wobbles?
It is genuinely exhausting, and I worry constantly about the people who are being left behind—the students who are giving up on becoming researchers because the pipelines are being cut, or the patients who are missing out on breakthroughs. It is a bizarre contrast to see medical miracles, like the drug that recently helped Ben Sasse survive pancreatic cancer, while simultaneously watching the infrastructure that funded that research crumble. I do have my rotation of shirts—the one that says “Up and not crying,” the one that says “This is not normal,” and my “living in unprecedented times” shirt—and I wear them because they feel like a necessary acknowledgment of the reality we’re in. As a journalist, I don’t have the option to turn it off, so I try to focus on the public service aspect of my job, which is shepherding the next generation through these fights so they can at least have an educated debate about what comes next.
What is your forecast for the American healthcare system?
My forecast is that we are headed toward a massive, high-stakes political showdown over healthcare in 2028 and 2029. We are seeing a repeat of the conditions that led to the fight over the Affordable Care Act in the early 2000s, where everyone involved—hospitals, drug companies, doctors, and labor unions—is profoundly unhappy with the status quo. Even the “haves,” those who have good insurance and are usually afraid of change, are starting to feel the squeeze of rising costs and shrinking access, with healthcare deserts appearing in less populated parts of the country. I am currently working on a project called “How Would You Fix It?” to call on the smartest people across the ideological spectrum because I believe it is time for another national conversation. I am not necessarily predicting that we will successfully solve everything, but I am very confident that the current state of things is unsustainable and that a major public struggle to redefine the system is just a few years away.
